EmailMe Form - LifelineUSA Dealer Application

Company Name *

DBA:

Primary Contact Name *

First Last

Secondary Contact Name

First Last

Owner *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Primary Contact Phone *

### - ### - ####

Secondary Contact Phone

### - ### - ####

Primary Contact Email *

Secondary Contact Email

Web Site *

Tax ID *

Image of your Business License *

Type of Business *

Partnership

Corporation

Sole Proprietor

LLC

Years in Business *

Trade References

Company *

Contact Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

Company *

Contact Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

More About You

Requested Dealer Level *

Shop/Installer

Reseller

WD

Image of your facility *

Image of your fire suppression system service area

Social media links (Please separate with commas)

Do you currently purchase Lifeline Fire and Safety Systems products from a dealer/distributor? *

Yes

No

If so, what dealer? *

Do you currently sell any other fire suppression systems, rain lights, harnesses, mirrors, or quick releases? *

Yes

No

If so, what brands? *

On average, what are the annual sales for items listed in the previous question? (in USD) *

What other fire suppression systems do you currently service? *

Will you expect Lifeline USA to drop ship for you? *

Yes

No

Do you plan to - *

Sell Online

Stock Product

Service Fire Systems (with approval)

How Did You Find Us? *

Comments / Questions